Successful pregnancy outcome in woman with history of Triple‐P procedure for placenta percreta

The incidence of abnormal invasion of the placenta (AIP) is increasing as the rate of Cesarean section increases. Recently, a conservative surgical technique called the 'Triple-P procedure' (perioperative placental localization, delivery with transverse uterine incision above the placenta, pelvic devascularization and placental non-separation) was proposed as an alternative to elective peripartum hysterectomy to reduce the risk of hysterectomy, and reduce blood loss and hospital stay1. We describe here a case of pregnancy subsequent to one managed using the Triple-P procedure for AIP. A 30-year-old woman, para 4, presented at our fetal medicine service at 34 weeks' gestation with placenta previa and four previous Cesarean sections (the first for breech presentation and subsequent ones were repeat electives). Posterior placenta previa with AIP extending towards the right broad ligament was diagnosed. The placenta was bulky with multiple lacunae and an irregular bladder interface, suggesting AIP (Figure 1). The pregnancy was delivered at our regional referral center via the Triple-P procedure. During consent, the woman declined sterilization (by tubal ligation), but, in the absence of safety data on pregnancy following the Triple-P procedure, was advised against future pregnancy. Due to the technically challenging nature of the case, the patient required laparotomy 18 h following surgery for continuing bleeding from vessels within the broad ligament. Hemostasis was achieved by sutures and administration of the local hemostat 'PerClot' (Starch Medical) into the diffuse bleeding vessels; hysterectomy was not required. Eighteen months later, the patient attended our maternity unit for a dating scan, which showed a single viable intrauterine pregnancy not suggestive of Cesarean scar pregnancy. She was counseled regarding risk of AIP recurrence. Subsequent reviews at 12, 20 and 32 weeks' gestation showed a high posterior placenta with no evidence of abnormal invasion. Elective Cesarean section with sterilization (by tubal ligation) was discussed and planned. The procedure was uncomplicated with minimal adhesions (Figure 2). The patient was discharged on day 3. AIP increases significantly the likelihood of serious maternal morbidity, including massive hemorrhage and damage to surrounding structures, and often culminates in hysterectomy2. For these reasons, clinicians are required to have an effective multidisciplinary approach to managing AIP. The UK Obstetric Surveillance System reported that, when clinicians made an attempt to either perform hysterectomy or conservatively manage AIP, without attempting to separate the placenta during surgery, bleeding was significantly reduced3. Whilst the Triple-P procedure has been adopted successfully and used in over 50 cases in the UK and an additional 25 cases elsewhere, there have been no subsequent pregnancies or deliveries described in these women. Reported outcome of pregnancy subsequent to that treated conservatively for AIP is uncommon, but there may be an increased risk of placenta accreta recurrence of nearly 30%4. As conservative treatment for AIP continues to grow in popularity, clinicians are more likely to encounter subsequent pregnancies in women with history of AIP. These women need careful management by experienced multidisciplinary teams after appropriate counseling.